Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is an anxiety condition that plagues a person with unwanted thoughts, images and impulses—called obsessions—that are impossible to suppress, causing him great stress and worry. He develops repeated, ritualized actions—compulsions—to alleviate the anxiety caused by these obsessions. Common obsessions include fear of contamination, fear of harm to himself or others, and fear that he might do something violent or terrible. Children with OCD, which affects around 3% of the population, may compulsively wash their hands, lock and relock doors, or touch parts of their bodies symmetrically in order to neutralize a fear and make themselves comfortable. They may also repeatedly ask questions and seek reassurance.

Parents should know that young children experience OCD differently than adolescents and adults. The disorder can manifest as early as 5, but a child may lack the self-awareness to recognize that his thoughts and fears are exaggerated or unrealistic, and he may not be fully aware of why he is compelled to perform a ritual; he just knows that it gives him what our expert calls a “just right feeling,” at least momentarily. Later, what professionals call “magical thinking” emerges: Though he knows it is far-fetched, a child finds himself compelled to scratch his right shoulder if he scratches his left shoulder so mom will be less likely to die in a car accident, for instance.  In any case, the response is highly structured and repetitive, making the child appear rigid and rule-bound and interfering with normal. And while all children seek reassurance from adults, children and adolescents with OCD pepper elders with repeated questions about the future.

 

Experts agree that most OCD obsessions fall in to the following categories: contamination (germs, waste, bodily fluids, chemicals, etc.), symmetry (lack of which could cause bad luck), fear of harm or responsibility for harm (the house will burn down), aggressive (I might hurt the baby) and sexual (What if I become a pedophile?). Since obsessions can be impulses as well as ideas or images, the compulsion in response to a dreaded impulse can be to avoid contact or problematic situations, or isolate oneself. Likewise, the rituals performed can be mental rather than physical, and go unrecognized by parents—and even the child.

Researchers believe a variety of factors contribute to OCD. Brain dysfunction, particularly in an area called the basal ganglia, has been tied to the disorder. And there seems to be a genetic component, as vulnerability to the disorder runs in families. At the same time, environmental factors appear to play a role, as children who see adults consistently responding to stress with compulsive behavior can develop similar behaviors. Even if a parent with OCD does not pass the condition to his children genetically, his behaviors can be picked up by the kids.

A diagnosis of OCD is based on a careful history and observation of the child. A clinician will collect information from many people—parents teachers, the child himself—in order to fully understand the extent of behaviors and feelings. He will make a diagnosis if your child has obsessions that are unwanted, cause marked anxiety, and are not “simply excessive worries about real-life problems.” Adolescents and adults, but not always children, will also recognize that the obsessions are a product of their own minds. Regardless of age, compulsions are undertaken in an attempt to neutralize the obsessions, and they are repetitive, rule-based, and “clearly excessive” or “not connected in a realistic way with what they are designed to neutralize.” The behavior interferes significantly with normal activities. In addition to the basic diagnosis, a professional can also determine the severity of the case and track the effectiveness of treatment using a widely accepted rating scale called Y-BOCS, or the Yale-Brown Obsessive Compulsive Scale.

Mild cases of OCD are often treated with cognitive behavior therapy alone, or medication alone; research shows them to be equally effective. But as symptoms intensify or impairment reaches the moderate to severe range, the best approach is the combination of CBT and medication.

 

Psychotherapeutic: OCD is best treated with cognitive behavior therapy, specifically a technique called exposure and response prevention. This technique introduces your child to the objects of his obsession in incremental doses in a controlled environment, in which he can experience his anxiety and distress without resorting to compulsions. Over time, as your child confronts his fears instead of attempting to neutralize them, he will become habituated, the anxiety response will diminish, and the obsession will become “boring.” The professional will work with your child to develop a “fear hierarchy,” and work on exposure from the easiest, least stressful trigger of OCD behavior up to the most dreaded. Much of the work and improvement is done at home, as the whole family is trained by the clinician to work on exposure tasks. Our clinicians caution that traditional talk therapy does not help children with OCD, as talking about the disorder can increase anxiety about obsessions. In fact, talk therapy can make symptoms worse.

 

Pharmacological: More severe cases of OCD are often treated with a combination of CBT and medication, including SSRIs, or selective seratonin reuptake inhibitors. The medication reduces anxiety and allows the child to be more amenable to doing the exposure therapy.  Once she has acquired skills to overcome the anxiety, medication can be decreased or discontinued.

 

Whether the treatment is behavioral or pharmacological or both, OCD patients will often return to their clinician in the years following their initial treatment for “booster sessions” to freshen up the skills they learned to control their anxiety levels.

Depression is often diagnosed in those with OCD. Other disorders that frequently occur alongside OCD include eating disorders, panic disorder, and Tourette’s syndrome. On the other hand, because of the intense stress and anxiety produced by OCD other disorders are often mistaken for it. A child with contamination obsessions, say, who cannot leave the classroom to “fix” his anxiety during school, may become so distracted that his condition is confused with attention-deficit hyperactivity disorder.

Is it my fault?
No. Though OCD has many causes—genetic, neurobiological, environmental—it is not the result of “unresolved issues” in childhood, or of a traumatic experience. However, even the best intentions of a parent of a child with OCD to help him manage his obsessions and to accommodate compulsions can actually perpetuate and exacerbate the disorder, so parent training and education is a key part of any treatment undertaken by a professional. The clinician will give you “do’s and don’ts” to help your child work to overcome OCD.
Do I have to tell my kid’s school?
If OCD is well managed by treatment, there is no reason the school needs to know. But teachers and school officials can be of great help to a child with OCD. Reading and writing in class may be a minefield for him, if a “bad” word or mistake triggers OCD behavior; a knowledgeable teacher will be able to respond more effectively to his distress or distraction. It may be beneficial to include as many caring adults as possible in your child’s treatment.
How is CBT different than traditional talk therapy?
Cognitive behavioral therapy exposes your child to his obsessions in carefully calibrated doses, to allow him to build up tolerance for the anxiety without resulting to the compulsions he has used to “fix” it. Gradually the obsessions lose their power. Talking about these obsessions and compulsion with a therapist who doesn’t really understand your child’s problem can actually exacerbate them. CBT for OCD is backed up by evidence, and therapists trained in the method are taught exactly how to employ it.
What should I ask a possible therapist?
You should make certain that your child’s therapist is experienced with OCD patients and the therapies used to treat it. Ideally, a professional will have seen hundred of OCD sufferers, and will have training in CBT, specifically exposure therapy. Beware the therapist who says, “Sure, I do a little bit of that.” Other approaches that are superficially similar, such as controlled desensitization, won’t be effective for an OCD patient.
How long will therapy last?
While some cases are handled relatively quickly, others can take quite a while to unravel. And for many people with OCD, managing the symptoms is a lifelong endeavor.
How involved should parents be in treatment?
Very. Most positive change in OCD patients comes between office sessions, as families educated in OCD therapies help their kids own their own treatment. This is not the kind of treatment parents refer to as “drop off and pick up,” in which parents are no more than chauffeur. If parents are not deeply involved in the treatment, it will not be as effective.
Will my child grow out of his obsessions and compulsions?
Compulsions temporarily alleviate the anxiety of OCD. But, like scratching a bug bite, performing them often results in increasingly severe obsessions and more impairing compulsions, a vicious spiral that can only be addressed by smart, focused therapy.